TOTAL CLAIMS
FOR
NUMBER FIUEO .
NUMBER EXTRA
TOTAL CHARGEABLE CLAIMS
—F^
1 \) minus 20=
INOEPENDEr^ CLAIMS
/'
- ' minus 3 «»
MULTIPLE OEPENOEhfT CLAIM PRES't
NT
□
PATENT APPUCATION FEE DETERMINATION RECORD
Effective October 1 . 2003
Application orDocket Number
CLAIMS AS FILED - PART I
SMALL ENTITY
TYPE \ 1
OTHER THAN
OR SMALL ENTITY
IT the difference in column 1 is less than zero, enter "0" in column 2
CLAIMS AS AMENDED - PART II
^Column 2) (Column 3)
<
z
CLAIMS
REMAINING
AFTER
AMENDMENT
HIGHEST
NUMBER
PREVIOUSLY
PAID FOR
PRESENT
EXTRA
IDMI
Total
*
Minus
-
UJ
S
Independent
*
1
Minus
<
NTATION OF MULTIPLE DEPENDENT CLAIM
J
(Column 2)
(Column 3)
:NTB 1
CLAIMS
REMAINING
AFTEfl
AMENDMENT
HIGHEST
NUMBER
PREVIOUSLY
PAID FOR
PRESENT
EXTRA
S
o
Total
*
Minus
z
tu
Independent
*
Minus
***
<
FIRST PRESENTATION OF MULTIPLE DEPENDENT CLAIM LJ
RATE
FEE
RATE
FEE
BASIC FEE
385.00
OR
BASIC FEE
770.00
X$9=
OR
XS18=
X43=
OR
X86=
+ 145=
OR
+290=
TOTAL
OR
TOTAL
SMALL ENTITY
OR
OTHER THAN
SMALL ENTITY
RATE
ADDI-
TIONAL
RATE
ADDI-
TIONAL
FEE
X$ 9=
OR
X$1Bs
OR
X86=
+145=
OR
+290=
TOTAL
' TOTAL
ADDFTFEE
On
AOOIt FEE
RATE
ADDI-
TIONAL
FEE
RATE
ADDI-
TIONAL
FE^
X$ 9=
OR
X$18=
X43=
OR
X86=
+145=
OR
+290=
TOTAL
ADOrr. FEE
OR
ADDtT.FEE
(Column 2)
(Column 3)
INTO 1
CLAIMS .
REMAINING
AFTER
AMENDMENT
NUMBER
PREVIOUSLY
PAID FOR
PRESENT
EXTRA
RATE
AODl-
TIONAL
FEE
RATE
ADDI-
TIONAL
Ul
S
o
Total
Minus
X$9=
OR
X$18=
z
Ui
1
Independent
* •
Minus
X43=
OR
X86=
FIRST PRESENTATION OF MULTIPLE DEPENDENT CLAIM LJ
+•145=
OR
• tfthe nbyineolui
«*Uth«>«ghMtNui
iim 1 is less tiwn ihe entry In calumn 2, write V in column 3.
irtpw Previously Paid Foe* IN THIS SPACE b less than 20. enlei
TOTAL
ADDIT.FEE
OR
TOTAL
ADOIT.FEE
m 0ie "Hiotiesl Number f^ewiousw rwa rorm ini&wwuco . . , .
i^TS^Number Pr" vioSyPid FoT (Total or IndependenI) Is the fiighBlTSiiSlief feund W
Paunt an* Tndsinttk Offin V.^
FORMFTMT8 {RmIOKO)